In mild to moderate papulopustulr rosacea, 10% sodium sulfacetamide and 5% sulfur cream or lotion are effective topical therapies of papulopustular rosacea and can be used to treat concomitant seborrheic dermatitis. It should be avoided in patients with sensitivity to sulfur or sulphonamides. Tinted and sunscreen containing preparations of these products are available, which appeal to some patients.
The choice among these topical agents can be difficult. There is individual variations in patients tolerance and response to treatment (what works for one patient may not always suit another). Most patients usually start with a metronidazole cream or azelaic acid gel applied twice daily.
Occasionally the response will be disappointing and this requires the physician to switch from one topical therapy to another to achieve optimal results. Patients are
adviced that initial prescription is likely to be successful, but that a follow-up
visit is required after three weeks to ensure that they have had a good response.
It is advisable that the physician becomes familiar with the tolerability of two or three topical agents on dry, normal, sensitive and oily skin as well as in patients with various skin types. With experience the clinician will be able to select the appopriate treatment to suit an individual patient.
Other topical therapy used to treat papulopustular rosacea includes, erythromycin 2% solution applied twice daily. This may be slightly drying and irritant and is probably not as effective as the other topical treatments but has the advantage that it can be used safely in the pregnant patient. Tretinoin 0.025% cream or lotion or 0.01% gel applied at night has the theoretical advantage of treating both the actinic damage as well as the rosacea, but is poorly tolerated by rosacea patients with dry sensitive skin and should be avoided in pregnancy. Isotretinoin 0.05% and erythromycin 2% alcohol gel applied as a thin film twice daily may also be effective, but again irritancy may reduce its acceptability to patients and it does not appear to have any advantage over the better tolerated metronidazole and azelaic acid products. Other topical therapies that have been reported to be effective in treating individual or small groups of patients with papulopustular rosacea include various sulfur containing products (often in combination with salicylic acid or precipitated sulfur with 0.75% hydrocortisone lotion), benzoyl peroxide gel (which is quite drying and poorly tolerated on the rosacea patient’s skin) sometimes used in combination with clindamycin 1% or erythromycin, and topical antimite preparations (Permethrin 1% or ivermectin 1.87% creams). There is insufficient
evidence to recommend these medications and the clinician is best advised to adhere to the FDA apapulopustular rosaceaoved and appropriately tested products. Only in the exceptional case will it be necessary to resort to any of these latter agents. Topical calcineurin antagonists such as tacrolimus and pimecrolimus initially showed promise in the treatment of papulopustular rosacea,but they may induce a rosaceiform eruption and so their use for these patients should probably be avoided. The method of application of topical therapies and how they should be used in relation to cosmetic and sun-block creams should be explained to the patient.
what is Rosacea
Rosacea is a common chronic inflammatory disorder of the hair follicles, sebaceous glands and vasculature of the face. The role of Demodex mite in the pathogenesis of Rosacea is controversial.
Rosacea sufferers have recurrent flushing, exacerbated by heat (shower, hot drinks), spicy foods, sunlight, cold, alcohol, and stress. They have sensitive skin, and may complain of dry and gritty eyes.
The peak incidence of Rosacea is 30—50 yr; Females being more affected than Males.
Rosacea sufferers may develop erythema, telangiectases, papules, and pustules of central face; there are no comedones in contrast to acne. Sebaceous hyperplasia, seborrheic dermatitis and facial lymphedema are also more common.
There are 4 Major Subtypes of Rosacea:
Erythematotelangiectatic, papulopustular, ocular, and phymatous.
Chronic inflammation may progress to rhinophyma (enlarged nose; in males). Ocular involvement is also common (e.g., gritty, conjunctival injection, styes, photophobia).
Investigations include clinical diagnosis; uncommonly, skin biopsy is indicated to rule out lupus or sarcoidosis.
Similar conditions that needs to be differentiated from Rosacea are: Acne, lupus erythematosus, perioral dermatitis, sarcoidosis, seborrheic dermatitis.
Treatment of Rosacea is based on severity and subtype.
Lifestyle modification:
Avoid triggers; sun protection and avoidance; facial massage for lymphedema.
Topical antibiotics:
Metronidazole 0.75% gel or 1% cream bid.
Sodium sulfacetamide lotion 10% bid.
Oral antibiotics (moderate to severe cases with inflammatory papulopustular component):
Tetracycline 500 mg po bid
Minocycline 100 mg po od—bid.
Doxycycline 20 mg po bid (subantimicrobial dose therapy) or 100 mg po qd–bid.
Isotretinoin (low dose); less commonly, topical retinoids may be used.
Laser therapy (e.g., PDL, IPL) for telangiectases and ablative laser (e.g., CO2) for rhinophyma.
Camouflage makeup (e.g., Dermablend, Covermark) for erythema.
Ophthalmologist to assess for ocular Rosacea (blepharitis, conjunctivitis, episcleritis).
